ACS Case Reviews in Surgery Vol. 2, No. 3 Solitary Cerebellar Metastasis as Herald Symptom of Primary Cecal Adenocarcinoma AUTHORS: CORRESPONDENCE AUTHOR: AUTHOR AFFILIATIONS: Samantha Knight, MDa; Adam Lipson, MDb; Dr. Samantha W.E. Knight a. Southern Illinois University School of Medicine, Mary Brandt, BAc; Jeffrey W. Cozzens, MD, FACS, 701 N. 1st Street Department of Surgery, Division of General Surgery, FAANSb; Elizabeth Dawn Wietfeldt, MD, FACS, Division of Surgery Springfield, IL FASCRSa,d General Surgery Residency Program b. Southern Illinois University School of Medicine, Southern Illinois University School of Medicine Department of Surgery, Division of Neurosurgery, PO Box 19638 Springfield, IL Springfield, IL 62794-9638 c. Southern Illinois University School of Medicine, Phone: (217) 414-0221 Springfield IL Email: [email protected] d. Springfield Clinic, Department of Colon & Rectal Surgery, Springfield IL Background We present a case of a 65-year-old female who initially presented with neurological complaints and was subsequently diagnosed with a solitary cerebellar metastasis of an otherwise asymptomatic cecal carcinoma. Summary A 65-year-old female presented to an outlying facility with the complaint of a five-day history of right-sided headache, nausea, and the sensation of drifting to the right upon ambulation. Computed tomography (CT) of the head revealed a left-sided cerebellar mass with associated mass effect. Additional imaging demonstrated small bowel mesenteric, retroperitoneal, periaortic, and periportal adenopathy, which, at the time, was thought to be secondary to lymphoma. CT-guided biopsy of the lymph nodes revealed metastatic adenocarcinoma, with the primary cecal tumor subsequently identified on colonoscopy. Due to concern for the development of obstructive hydrocephalus, the patient underwent craniotomy for gross total resection of the metastatic lesion. Postoperatively, the patient was treated with radiotherapy and FOLFOX/Avastin combination chemotherapy. Conclusion Reports on the discovery of metastatic cecal carcinoma revealed by a solitary cerebellar lesion remain a rarity in current medical literature. This case highlights the importance multidisciplinary collaboration when diagnosing and managing late stage malignancies, especially with an unconventional presentation of a primary neoplasm. Keywords Cerebellar metastasis, cecal adenocarcinoma, neurosurgery, colorectal DISCLOSURE: MEETING PRESENTATION: The authors have no conflicts of interest to disclose. Illinois Chapter of the American College of Surgeons CONTRIBUTORS STATEMENT: All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. To Cite: Knight S, Lipson A, Brandt M, Cozzens JW, Wietfeldt ED. Solitary Cerebellar Metastasis as Herald Symptom of Primary Cecal Adenocarcinoma. ACS Case Reviews in Surgery. 2019;2(3):24-28. American College of Surgeons – 24 – ACS Case Reviews. 2019;2(3):24-28 ACS Case Reviews in Surgery Knight S, Lipson A, Brandt M, Cozzens JW, Wietfeldt ED Case Report A 65-year-old, right-handed woman presented to an outlying community hospital with a five-day history of right-sided headache and nausea. Upon presentation, the patient denied any changes in vision, weakness, numbness and tingling in her extremities, shortness of breath, chest pain, abdominal pain, hematochezia or melena, bowel or bladder dysfunction. Further questioning revealed that the patient had noted a sensation of drifting to the right while ambulating for several months, though she denied any recent falls. Past medical history was significant for a distant diagnosis of iron-deficiency anemia. Her surgi- cal history included laparoscopic cholecystectomy and three cesarean sections. Social history was significant for a 20-pack-per-year smoking history and occasional alcohol consumption. Review of family history revealed no rela- tives with bowel, brain, or solid-organ malignancy. Med- ication included oral iron supplements and a daily baby aspirin. Remarkably, on exam, the patient was neurologi- cally intact, and no abnormalities in gait or coordination were noted. Laboratory results revealed no presence of anemia (hemoglobin 12.4 g/dL, hematocrit 37.8 percent, MCV 91.7 fL) or leukocytosis (WBC 9.4 x 10^3/uL); alkaline phosphatase was found to be only slightly elevated (109 U/L). All other laboratory values were unremarkable. Portable chest radiograph was without significant findings. A non-contrast computed tomography (CT) of the head was ordered, which revealed a 2.2 cm left-sided cerebellar mass with associated mass effect on the fourth ventricle. Due to these findings, the patient was transferred to our Figure 1. MRI Brain demonstrating contrast-enhancing coin lesion in left facility, where more comprehensive care could be rendered. cerebellum. A. Sagittal T1WI B. Coronal T1W1 postcontrast C. Axial T1WI Additional imaging was ordered, including magnetic reso- D. Axial T1W1 postcontrast E. Axial T2WI F. Axial T2WI FLAIR nance imaging (MRI) of the brain with contrast, which demonstrated a 3 cm contrast-enhancing mass within the left cerebellum, with mild mass effect on the fourth ventri- cle without hydrocephalus (Figure 1). American College of Surgeons – 25 – ACS Case Reviews. 2019;2(3):24-28 ACS Case Reviews in Surgery Knight S, Lipson A, Brandt M, Cozzens JW, Wietfeldt ED CT of the chest, abdomen, and pelvis was performed to evaluate a primary tumor source, revealing soft tissue masses that likely represented adenopathy within the small bowel mesentery and adjacent to the cecum as well as retro- peritoneal adenopathy, including an enlarged lymph node between the inferior vena cava and portal vein approxi- mately 2 cm in diameter. Additional enlarged lymph nodes were identified between the aorta and inferior vena cava Figure 3. CT-guided biopsy A. CT-guided biopsy of enlarged lymph as well as left periaortic retroperitoneal lymph nodes mea- node present between the inferior vena cava and portal vein, measuring suring 1.4 cm, 1.7 cm and 2 cm, in diameter, respective- approximately 2 cm in diameter. B. CT-guided biopsy needle shown sampling enlarged lymph node. ly. Irregular wall thickening of the cecum was also noted (Figure 2). Gastroenterology was consulted, whose work-up yielded findings of a cecal mass and several tubular adenomatous polyps of the distal colon on colonoscopy (Figure 4). Biop- sy of these lesions was performed, and surgical pathology of the cecal mass demonstrated invasive, moderately-dif- ferentiated adenocarcinoma. Immunohistochemical anal- ysis for microsatellite instability demonstrated preserved DNA-mismatch repair function (positive expression of hMLH-1, hMSH-2, hMSH-6, and PMS2). Figure 2. CT chest/abdomen/pelvis with contrast. A: Enlarged lymph node present between the inferior vena cava and portal vein, measuring approximately 2 cm in diameter. B: Enlarged lymph nodes between the aorta and inferior vena cava, up to 1.4 cm in diameter and a left periaortic retroperitoneal lymph node measuring up to 1.7 cm in diameter, and more inferior left periaortic retroperitoneal lymph node measuring approximately 2 cm in maximal dimension. C: Soft tissue masses in the small bowel mesentery, primarily in the right lower quadrant. One of these is seen measuring approximate 2 cm in diameter. D: Several other soft tissue masses adjacent to the cecum, measuring up to 2 cm in diameter. Figure 4. Images captured at colonoscopy. A: Diverticuli within sigmoid colon, B: Half circumferential mass found in the cecum, multiple biopsies In all, it was felt that such nonspecific retroperitoneal and were taken of the lesion and a tattoo was applied. C: Sessile polyp small bowel mesenteric adenopathy likely represented found in the descending colon, polypectomy was performed with snare cautery. D: Large pedunculated polyp was found in the sigmoid colon lymphoma. CT-guided core needle biopsy of the mesen- E: Polypectomies were performed using snare cautery and a tattoo was teric and periaortic lymph nodes (Figure 3) was pursued in applied. F: Additional large pedunculated polyp was found in the sigmoid colon, polypectomy was performed using snare cautery and the wound order to obtain a histopathological diagnosis. This revealed site was closed by placing hemoclips. G: Otherwise normal sigmoid colon metastatic adenocarcinoma, immunohistochemically con- mucosa. H: Normal retroflexion view within the rectum. sistent with a colorectal primary lesion (tumor cells were positive for cytokeratin 20 and CDX2; negative for cyto- keratin 7, TTF-1, Pax 8 and vimentin). American College of Surgeons – 26 – ACS Case Reviews. 2019;2(3):24-28 ACS Case Reviews in Surgery Knight S, Lipson A, Brandt M, Cozzens JW, Wietfeldt ED Colorectal surgery was consulted; however due to the with 70 and 40 percent of patients having lung and liver patient’s stage IV, TXN2M1 diagnosis, no colonic resec- metastases, respectively, at diagnosis of brain metastasis.9 tion was indicated acutely. The patient’s case was discussed Additionally, postmortem studies have demonstrated that at an interdisciplinary tumor board meeting, where it was at the time of death, between 2 and 3 percent of patients agreed that, should her cecal mass become obstructing, or who die from CRC harbor occult brain metastases.5,6 her iron deficiency anemia recur, surgical resection or pal- liative stenting would be discussed at that point in time. The cerebellum is the involved site in 55 percent of met- astatic CRC cases to the brain.5,6,10 It is hypothesized